Multiple Imaging Mode Tissue Marker

ABSTRACT

An intracorporeal marker for marking a site within living tissue of a host having a body of porous hydroxyapatite whose physical properties permit the body to be distinguished from human soft tissue under visualization using ultrasonic and radiation imaging modalities.

PRIORITY DATA AND INCORPORATION BY REFERENCE

This application is a U.S. nation phase of International Application No. PCT/US2007/087211, filed Dec. 12, 2007, which claims priority to U.S. Provisional Patent Application No. 60/869,636, filed Dec. 12, 2006, which are incorporated herein by reference in their entirety.

TECHNICAL FIELD

The invention relates generally to a biopsy tissue markers. More specifically, the invention further relates to a biocompatible tissue site marker that is visible under various modes of imaging.

BACKGROUND ART

Advances in modern medical imaging technologies such as X-ray, ultrasound, or magnetic resonance imaging make it possible to identify and to biopsy tumors while they are still small. When dealing with a small tumor, especially after a portion of the tumor has been removed for biopsy, it is sometimes difficult to locate the tumor at a later time for treatment. This is particularly true in the case of tumors in the breast, where the ability to visualize a small growth may depend upon the manner in which the breast is positioned or compressed during the procedure. In addition, prior to surgically removing a tumor, it is often advantageous to try to shrink the tumor by chemotherapy or irradiation. This is especially true in the case of breast cancer, where conservation of breast tissue is a concern. Shrinkage of the tumor can sometimes make it difficult for the surgeon to locate the tumor.

A solution to this problem is to place a marker within the target tissues at the time of biopsy which can be visualized under a variety of imaging modalities to facilitate finding the tumor at a later time. When a suspicious mass is detected, a sample is taken by biopsy, often, but not necessarily, using a specialized instrument such as a biopsy needle. The needle is inserted in the breast while the position of the needle is monitored using fluoroscopy, ultrasonic imaging, X-rays, MRI or other suitable imaging modalities.

In a new procedure, called stereotactic needle biopsy, the breast is compressed between the plates of a mammography apparatus and two separate X-rays are taken from different points of reference. The exact position of the mass or lesion is calculated within the breast. The coordinates of the lesion are then programmed into a mechanical stereotactic apparatus which guides the biopsy needle to the lesion.

Irrespective of the biopsy technique, the surgical site may need to be examined or accessed for surgical treatment of a cancerous lesion. Treatment requires the surgeon or radiologist locate the lesion precisely and this may need to be done repeatedly over a period of time. Since treatment may alter the host tissue, the function of a marker even more important.

U.S. Pat. No. 6,725,083 for “Tissue site markers for in vivo imaging” describes biopsy site markers and methods that permit conventional imaging techniques to be used, such as ultrasonic imaging. The biopsy site markers have high ultrasound reflectivity due to high contrast of acoustic impedance resulting from gas-filled internal pores. The markers may have a non-uniform surface. The patent discloses the use of materials such as metal, ceramic materials, metal oxides, polymer, and composites and mixtures thereof.

U.S. Pat. No. 6,350,244 for “Bioabsorable markers for use in biopsy procedure” discloses a breast tissue marker that allows the marker to be left in place avoiding the need for surgical removal. One type of marker takes the form of hollow spheres made of polylactite acid filled with iodine or other radiopaque material to make them visible under X-rays and/or ultrasound. The radiopaque materials are also bioabsorbable. Another type of marker disclosed is a solid marker of pre-mixed radiopaque material and a bioabsorbable material. The solid markers may also include dyes and radioactive materials.

U.S. Pat. No. 6,347,241 for “Ultrasonic and x-ray detectable biopsy site marker and apparatus for applying it” shows a biopsy site marker of small bodies or pellets of gelatin which enclose substantially a radioopaque object. The pellets are deposited at the biopsy site by an applicator device inserted in the biopsy site. Several gelatin pellets are deposited through the tube. The radio opaque core in the gelatin bodies are of a non-biological material and structure which are readily identified during X-ray observations.

U.S. Pat. No. 6,161,034 for “Methods and chemical preparations for time-limited marking of biopsy sites” describes markers that remain present to permit detection and location of the biopsy site. The markers are later absorbed by the host. The patent discloses gelatin, collagen, balloons and detectability provided by AgCl; Agl; BaCO₃; BaSO₄; K; CaCO₃; ZnO; Al₂O₃; and combinations of these.

US Patent Publication No. 2006/0079805 for “Site marker visible under multiple modalities” describes site markers that include balls or particles which are bonded together to form a marker body. The balls or particles are made from biocompatible materials such as titanium, stainless steel or platinum. The balls or particles are described as being bonded together by sintering or by adhesive such as epoxy. An alternative embodiment has at least one continuous strand of wire of biocompatible material such as titanium, stainless steel, platinum, or other suitable material, compressed to form a mass that resembles a ball of yarn. Another alternative is a resonating capsule, or a rod with drilled holes.

US Patent Publication No. 2006/0036165 for “Tissue site markers for in vivo imaging” shows ultrasound-detectable markers whose shapes are distinct in an image from biological shapes. Various shapes are disclosed including cylinders, coils, and other more complex shapes.

It is believed that most known tissue markers have a disadvantage in that they are not visible under all available imaging modalities. The features of a marker that make it stand out under X-rays do not necessarily make them stand out under MRI or ultrasound imaging. One prior art mechanism for addressing the need for multiple-imaging-mode markers is to employ a combination of metal structure and biodegradable foam to provide ultrasonic imaging visibility, MRI visibility and x-ray visibility. In this case, the metal structure provides x-ray visibility and biodegradable foam provides visibility in ultrasonic imaging.

There is a need for site markers made from biocompatible materials that are visible under various modes of imaging to reduce the number of procedures that patients must undergo in detection and treatment of cancer or any disease requiring the user of tissue markers. It will be a valuable contribution to the art for a marker with a simple design and superior biocompatibility can be provided. Also, selectable bioabsorability by the host may be an advantage as well.

SUMMARY OF THE INVENTION

A hydroxyapatite or porous metal or non-metal-based biopsy marker is visible in multiple imaging modalities. In a preferred embodiment, hydroxyapatite, a component of natural bone, is used. This material is highly visible when viewed using X-ray imaging. The ultrasonic visibility may be provided by creating one or more voids within the hydroxyapatite marker and entrapping a biocompatible gas within the void or voids. The biocompatible gas provides a low density structure within the marker body which provides high contrast when viewed using ultrasonic imaging equipment. Also, hydroxyapatite has the advantage of being very biocompatible. In addition, if biodegradability is desired, hydroxyl apatite is capable of being rendered in a form that makes it long-lasting, but ultimately biodegradable as well.

The manufacture of porous hydroxyapatite performs or molded forms is well known. The hydroxyapatite can be made porous by many methods known in ceramic manufacturing art. These methods include but not limited to: molding the hydroxyapatite particles to a desired geometry and then sintering the green mass. The preferred porosity levels in porous Hydroxyapatite could range from 30% to 80%, and more preferably, from 60 to 80%. One exemplary method is to mix powdered hydroxyapatite with a removable material to form a slurry which when hardened can be removed and then to sinter the hydroxyapatite to form a porous structure. Examples of removable material include various soluble polymers, naphthalene, and others. Purified hydroxyapatite powder can be made from known processes or obtained from natural sources such as coral.

In an embodiment, a porous hydroxyapatite article may be obtained, for example from commercial sources such as Berkeley Advanced Biomaterials, Inc and incubated in carbon dioxide atmosphere to fill the pores. The disk is visible under X-ray and ultrasonic imaging.

Material other than hydroxyapatite can be used to make a marker visible under multiple imaging modalities. For example, a biocompatible porous ceramic may be used alone or in combination with a biocompatible impermeable jacket, such as a coating of PTFE. The porous ceramic material can be produced by sintering particles with a sufficient void fraction to make the resulting article distinct under ultrasound. Ceramics containing mixtures of materials may be employed to enhance radio-opacity. For example, ceramics can contain metallic inclusions. Ceramic particles (or metal-ceramic particle mixtures) having a packing density of a desired fraction, for example 70%, may be sintered to create a mass. The result may have no, or limited, connections between the void spaces so that the result needs no impermeable jacket to avoid the voids filling with fluids. Alternatively, a coating may be provided to prevent ingress of fluids. The coating need not be mechanically continuous over the article if it is sufficient to retard ingress of moisture. For example, the coating material may be hydrophobic. In a variation, techniques used for making refractory foams may be employed to create a marker.

In another embodiment, a biocompatible porous metal is used in place of hydroxyapatite. The porous metal can be produced by mechanical methods known in the art such as sand blasting. Other methods such as laser etching, chemical etching or powder metallurgical methods including sintering could also be used. In one preferred approach, porous metals are obtained by compacting a metal powder to a desired shape in presence of a polymeric and non-polymeric binder and then sintering the metal powder particles to form a homogenous metal mass with predetermined porosity/density. Many metals and alloys suitable for long term implant could be used and these include but not limited to: Nitinol, gold, silver, stainless steel, cobalt-chromium alloy, titanium, tantalum, and tungsten or combination thereof.

The shape and geometry of the porous biopsy marker can depend on the clinical application. In general cylindrical, spherical, disk like shapes are preferred. Irregular shapes may also be used.

According to an embodiment, an intracorporeal marker marks a site within living tissue of a host. The marker has a body of porous hydroxyapatite whose size and shape permit visualization under ultrasonic and radiation imaging modalities. Preferably, the shape is generally cylindrical. In one embodiment, the marker has a lower density core region and a higher density surface region.

According to an embodiment, an intracorporeal marker marks a site within living tissue of a host. The marker has an ultrasound-detectable portion defined by boundaries that are distinctly different from normal tissue features. The ultrasound-detectable portion is of a material that exhibits high contrast in acoustical impedance compared to the host tissue. The same portion, or a different portion, of a material exhibits high contrast in at least one type of radiation imaging. The portion or the same or different portion includes at least one of porous ceramic, a porous metal, and a porous hydroxyapatite.

In a variation, the shape is generally cylindrical. In another variation, the marker has a lower density core region and a higher density surface region. A water-impermeable coating layer may be provided to seal the marker against penetration by fluid, particularly where the voids within are channeling voids. In a particular embodiment the marker is of hydroxyapatite and in a further, more specific variation, the surface region of the marker has a higher density.

According to an embodiment, an intracorporeal marker for marking a site within living tissue of a host has a porous body of hydroxyapatite. The pores of the porous body are of such a size as to maximize the visibility of the body under ultrasonic imaging. In a variant, the body has a surface of higher density than a major fraction beneath the surface.

According to an embodiment, an intracorporeal marker marks a site within living tissue of a host. The marker includes a body of porous hydroxyapatite whose physical properties permit the body to be distinguished from human soft tissue under visualization using ultrasonic and radiation imaging modalities. The body can have various shapes, a preferred shape is a cylindrical shape. In a preferred embodiment, the body has gas-filled pores. In another preferred embodiment, the body has a core and a surface region, the core region having a lower density than the surface region.

Note that, as used in this specification, the term soft tissue is intended to characterize non-skeletal tissue which relatively transparent to X-rays such that tissue such as bone and some ligaments, cartilage, and fibrous tissue can be distinguished from it. Thus, a hydroxyapatite marker may be substantially visible under X-rays when placed in soft-tissue but might be hard to distinguish from non-soft-tissue.

According to another embodiment, an intracorporeal marker marks a site within living tissue of a host. The body includes at least one material that exhibits detectable difference in acoustical impedance relative to human soft tissue. The at least one material also exhibits detectable difference in radiation impedance relative to human soft tissue. The at least one material includes at least one of porous ceramic and a porous metal. Preferably, the body has a shape that is generally cylindrical. In a variation of the embodiment, the body has a core and a surface region, the core region having a lower density than the surface region. In another variation of the embodiment, the body has a surface and the surface has a water-impermeable coating layer. The at least one material preferably includes hydroxyapatite and preferably the material is solely hydroxyapatite.

According to another embodiment, an intracorporeal marker marks a site within living tissue of a host. The marker has a porous body of hydroxyapatite, the body having pores filled with gas. The sizes of the pores and the gas are such that the body can be visualized under ultrasound. In a variation, the body has a core and a surface region, the core region having a lower density than the surface region.

According to another embodiment, a method of in vivo identification of a position in soft tissue includes inserting a marker containing hydroxyapatite at a position in soft tissue of a living host; passing ultrasonic energy through the soft tissue to form an ultrasound image of the marker; and passing radiant energy through the soft tissue to form an X-ray image of the marker. Preferably, the hydroxyapatite defines a porous structure and more preferably, the body consists substantially of hydroxyapatite.

According to another method of in vivo identification of a position in soft tissue, a marker containing hydroxyapatite is inserted at a position in soft tissue of a living host. Ultrasonic energy is then passed through the living host to form an ultrasound image of the marker. The image is then used to locate a site for a medical treatment. Preferably, the hydroxyapatite is porous. The marker may consist substantially of hydroxyapatite.

According to another embodiment, a method of in vivo identification of a position in soft tissue, includes: inserting a marker containing hydroxyapatite at a position in soft tissue of a living host; passing radiant energy through the living host to form an X-ray image of the marker using the image to locate a site for a medical treatment. Preferably, the hydroxyapatite is porous. The marker may consist substantially of hydroxyapatite.

According to another embodiment, a method of in vivo identification of a position in soft tissue, includes: inserting a marker containing a porous ceramic at a position in soft tissue of a living host; passing ultrasonic energy through the living host to form an ultrasound image of the marker; passing radiant energy through the living host to form an X-ray image of the marker; using the image to locate a site for a medical treatment. Preferably, the porous ceramic includes hydroxyapatite and more preferably, the porous ceramic is substantially made of hydroxyapatite.

According to another embodiment, a method of in vivo identification of a position in soft tissue, includes: inserting a marker containing a porous ceramic at a position in soft tissue of a living host; passing ultrasonic energy through the living host to form an ultrasound image of the marker; passing energy through the living host to form an image of the marker based on a non-ultrasound imaging modality; using the image to locate a site for a medical treatment. Preferably, the porous ceramic includes hydroxyapatite and more preferably, the porous ceramic is substantially made of hydroxyapatite.

BRIEF DESCRIPTION OF THE DRAWINGS

The accompanying drawings, which are incorporated herein and constitute part of this specification, illustrate exemplary embodiments of the invention, and, together with the general description given above and the detailed description given below, serve to explain the features of the invention.

FIG. 1 is a cross-sectional view of a tissue marker with a gas-impermeable (or resistant) casing.

FIG. 2 shows a tissue marker from the side which is cylindrical shape according to exemplary embodiments.

FIG. 3 is a cross-sectional view of a tissue marker with a gas-impermeable or liquid impermeable coating and a porous metal, ceramic, or hydroxyapatite core.

FIG. 4 is a cross-sectional view of a tissue marker with a porous outer layer of metal, ceramic, or hydroxyapatite and a relatively solid metal, ceramic, or hydroxyapatite core.

FIG. 5 illustrates a monolithic porous marker, such as of hydroxyapatite.

FIG. 6 illustrates the marker of FIG. 5 with a relatively solid outer layer, such as a porous material of the core that has been treated to densify the outer surface region to make it relatively less susceptible to having the gas in the porous gas-filled voids from being displaced by body fluids.

FIG. 7 illustrates a porous core with a relatively solid outer layer which may be of the same or a different material from the core.

DISCLOSURE OF THE INVENTION

Ceramics with voids in them, such as ceramic foams, are often used as filtering materials. Some are used for filtering molten metal, for example. Such materials may be manufactured in a variety of different ways. Ceramic foam filters are generally made by impregnating a polymeric foam with an aqueous slurry of ceramic material containing a binder. The impregnated foam is dried to remove water, and the dried impregnated foam is fired to eliminate the polymer material. This leaves the ceramic foam. This process is often used to create a channelized product but recipe variations, such as a lower quantity of foaming agent, can produce non-channelized product.

Foamed glass methods of manufacture and articles of manufacture are disclosed in U.S. Pat. No. 5,972,817, “Foamed Glass Article for Preparing Surfaces, Use Therefor, and Method of Making Same” to Haines et al.; U.S. Pat. No. 5,821,184, “Foamed Glass Article for Preparing Surfaces, Use Therefore and Method of Making Same” to Haines et al.; U.S. Pat. No. 5,928,773, “Foamed Glass Articles and Methods of Making Same and Methods of Controlling the PH of Same Within Specific Limits” to James C. Andersen; and published US Pat. Appl. No. 20040016195 for “Foamed glass article for use as thermal energy control media;” each of which is hereby incorporated by reference and attached hereto as if fully set forth herein.

The voids may channel; i.e., they may generally intersect or communicate with each other and the external surface. Alternatively, they may be of a so-called closed cell type where the voids do not communicate with each other or the external surface. In void channeling materials or materials which are naturally rough or porous, it is preferred for the matrix to be hydrophobic or that the surface of the marker be sealed by an impermeable, preferably hydrophobic, coating. This helps to resist filling of the voids or surface pits with aqueous fluid. FIG. 1 illustrates, in section, a marker 100 having a core 105 with a coating 110 overlying its surface. The coating also may promote the biocompatibility of the surface as well as ensure against filling of voids. FIG. 2 illustrates a side view of a marker 99 which is consistent with the embodiment of FIG. 1 as well as with other embodiments disclosed herein. FIG. 3 illustrates a marker with a porous non-ceramic material, such as sintered metal alloy. A coating 160, as described in the embodiment of FIG. 1, may be provided in this particular marker 150.

FIG. 4 illustrates a two-component marker 200 of porous hydroxyapatite 210 on an external layer over a core 107 which may be of a different material, such as one which is predominantly visible under X-ray imaging. The external layer 210 is biocompatible owing to the use of hydroxyapatite. The porosity of the outer layer 210 enhances the marker's visibility under ultrasonic imaging. The outer layer 210 also provides the biocompatibility of hydroxyapatite on the entire outer surface of the marker 200. The core 107 may be metallic, ceramic composite (with metallic material to enhance X-ray absorption), or it may be a non-porous, or a less porous form of the outer layer 210, for example, hydroxyapatite. In an alternative embodiment, the outer layer 210 and core 107 materials discussed with reference to the FIG. 4 embodiment may be reversed. For example, the core 107 may be porous and the outer layer 210 could be solid or relatively more solid than the core.

FIG. 5 illustrates a preferred embodiment of a single-component porous hydroxyapatite marker 250 which is of porous hydroxyapatite 109 throughout. A marker 255 which is a variation on the embodiment 250 is shown in FIG. 6 in which a core 109 of porous hydroxyapatite is treated on its surface to close any channeling and/or smooth its surface to create a denser outer layer 260 of hydroxyapatite. Another variation of a hydroxyapatite marker is shown in FIG. 7 in which the marker 300 has a porous hydroxyapatite core 111 and a more solid, or completely solid, outer layer 310. Variations of these hydroxyapatite embodiments are also considered useful, for example, a porous outer layer with a non-porous or low porosity core and a dense core with a porous outer layer that has been treated to form a thin dense outer layer as in the embodiment of FIG. 6. In the latter embodiment, the porosity would change from dense at the center, to porous toward the surface and then back to dense at the surface. Table 1 illustrates various embodiments with H referring to hydroxyapatite, M referring to metal, C referring to ceramic, and J referring to an impermeable coating and the subscripts P and S referring to porous and solid (or relatively low porosity). Note that other combinations may be employed, the table providing merely a summary of some preferred options.

TABLE 1 Structural embodiments of biopsy markers 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Core H_(P) M_(P) C_(P) H_(S) M_(S) C_(S) H_(P) M_(P) C_(P) H_(S) M_(S) C_(S) M_(P) C_(P) M_(S) Outer layer H_(S) M_(S) C_(S) H_(P) M_(P) C_(P) — — — H_(P) — — M_(S) C_(S) — Surface layer — — — H_(S) M_(S) C_(S) — J J — — — J J J

Although referred to as porous, the materials above may include one or more discrete voids formed non-randomly. For example, the voids may be formed by binding filaments of the marker material together, for example ultrasonic welding of thin wires to form voids in a metal marker or component of a marker. Voids may be also be formed by other processes such as machining, chemical etching, laser etching, etc. In general, where the embodiments are described as being porous, such alternative types of voids, including a single void chamber, are also contemplated. The voids may be formed by entrapping a biocompatible gas within the void or voids.

The markers may be incubated in carbon dioxide atmosphere to fill the voids with the gas. As discussed above, various methods may be used to create the hydroxyapatite bodies. These methods include but not limited to: molding the hydroxyapatite particles to a desired geometry and then sintering the green mass. The preferred porosity levels in porous Hydroxyapatite could range from 30% to 80%, and more preferably, from 60 to 80%.

Preferably porous portions are have a sufficient void fraction and a size chosen to ensure the marker is distinct under ultrasonic imaging. Porous ceramic material can be produced by sintering particles with a sufficient void fraction to make the resulting article distinct under ultrasound. As indicated above, ceramics containing mixtures of materials may be employed to enhance radio-opacity. For example, ceramics can contain metallic inclusions. Ceramic particles (or metal-ceramic particle mixtures) having a packing density of a desired fraction, for example 70%, may be sintered to create a mass. The result may have no or limited connections between the void spaces so that the result needs no impermeable jacket to avoid the voids filling with fluids. Alternatively, a coating may be provided to prevent ingress of moisture. The coating need not be mechanically continuous over the article if it is sufficient to retard ingress of moisture. For example, the coating material may be hydrophobic. In a variation, techniques used for making refractory foams may be employed to create a marker.

In embodiments where a biocompatible porous metal is used the metal porosity may be obtained by compacting a metal powder to a desired shape in presence of a polymeric and non-polymeric binder and then sintering the metal powder particles to form a homogenous metal mass with predetermined porosity/density. Many metals and alloys suitable for long term implant could be used and these include but not limited to: Nitinol, gold, silver, stainless steel, cobalt-chromium alloy, titanium, tantalum, and tungsten or combination thereof.

The shape of the marker can depend on the clinical application. In general cylindrical, spherical, disk like shapes are preferred. Irregular shapes may also be used.

According to a feature of the above embodiments, a marker of the any of the above described structures and compositions may be used according to the following method which may include steps 1 and 2, steps 1 through 3, or steps 1 through 4, according to different embodiments.

Step 1. Insert a marker at a location. The location can be marked at a time and location of biopsy or otherwise positioned in a tissue mass.

Step 2. Identify a location of the marker using a first imaging modality. The modality may be X-ray-based imaging or ultrasound-based imaging. This step may include passing a corresponding form of energy through a soft tissue mass of a living host.

Step 3. Identify a location of the marker using a second imaging modality that is different from the first imaging modality in step 2. The second imaging modality may be X-ray-based imaging or ultrasound-based imaging. This step may also include passing a corresponding form of energy through a soft tissue mass of a living host.

Step 4. Surgically remove the marker.

Note that while the principal embodiments described above had a generally symmetrical configuration, it is also possible to form asymmetrical embodiments. For example, bodies having different materials that can be imaged using different modalities can be located adjacent each other on respective sides of the body. Also, for example, cylindrical embodiments with a low density portion and high density portion, each on a respective side of the axis in a first embodiment, or each on a respective end of (displaced along the axis) could be provided. Thus, the manner in which material is distributed is not necessarily confined to the particular examples shown. Such embodiments could be imaged using multiple imaging modalities.

While the present invention has been disclosed with reference to certain embodiments, numerous modifications, alterations, and changes to the described embodiments are possible without departing from the sphere and scope of the present invention, as defined in the appended claims. Accordingly, it is intended that the present invention not be limited to the described embodiments, but that it has the full scope defined by the language of the following claims, and equivalents thereof. 

1. An intracorporeal marker, for marking a site within living tissue of a host, comprising: a body having a core and a surface region, the core being of porous hydroxyapatite whose physical properties permit the body to be distinguished from human soft tissue under visualization using ultrasonic and radiation imaging modalities, and wherein the core region has a lower density than the surface region.
 2. The marker of claim 1, wherein the body has a cylindrical shape.
 3. The marker of claim 1, wherein the body has gas-filled pores.
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 8. The marker of claim 1, wherein the the surface region has a water-impermeable coating layer.
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 11. An intracorporeal marker for marking a site within living tissue of a host, comprising: a porous body of hydroxyapatite having a center and a surface, the body having pores filled with gas, the sizes of the pores and the gas being such that the body can be visualized under ultrasound, wherein a porosity changes from dense at the center of the body, to porous toward the surface, and back to dense at the surface.
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 13. A method of in vivo identification of a position in soft tissue, comprising: inserting a marker containing hydroxyapatite at a position in soft tissue of a living host; passing ultrasonic energy through the soft tissue to form an ultrasound image of the marker; and passing radiant energy through the soft tissue to form an X-ray image of the marker.
 14. The method of claim 13, wherein the hydroxyapatite defines a porous structure.
 15. The method of claim 13, wherein the marker includes a body consisting substantially of hydroxyapatite.
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